Commissioning

Is it possible to have strong general practice (GP) ownership of a primary health care organisation, whilst pursuing a population health agenda? Geoff Meads termed this age-old tension between general practice and public health the attempt to mix oil and water.

In mineral-rich but water-poor Australia recently, I had a strong sense of déjà-vu about the general practice-public health tension.

Australia is setting up a national network of 'Medicare Locals' as part of wider health reforms. These new organisations will be responsible for planning more integrated, local primary and...

With the showers has come a certain malaise tinged with queasy uncertainty.

This could be a post-Bill slump in the NHS, a response to the long grind of making cuts with no end in sight, and the sheer weight of detail to be worked through with respect to the mass reorganisation outlined in the now Health and Social Care Act.

The queasiness extends beyond health, look at local Government for example facing an average six per cent cuts rather than a ‘flat real’ settlement as in health.

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The introduction of the Health and Social Care Act 2012 was trumpeted in some quarters (including, apparently, the Cabinet room) as a hard-won victory for Andrew Lansley and his plans to ‘liberate the NHS’.

For the battalion of health service managers, however, the campaign has now begun in earnest. It is they who have to take the legislation, translate its complex clauses into practical plans, and determine how far Lansley's hopes will be realised and the fears of his detractors proven or not.

NHS...

Amongst all of the health reform activities in the United States, the formation of accountable care organisations (ACOs) is considered one of the more promising for bending the health care cost curve while improving patient outcomes.

ACOs are comprised of a group of providers who are held accountable for the cost and quality of care for a defined population of patients.

Successful ACOs are expected to manage costs by aligning incentives for hospitals,...

High stakes with the Health and Social Care Bill last week. But at our Health Policy Summit 2012 we pushed aside for a minute big reform, structures, and long run consensus-dividers such as competition/choice, public/private, and command versus autonomy.

Instead, we majored on – as guest Don Berwick so thoughtfully put it – ‘contextually adaptive changes’.

A physician who was formerly chief of the Centers for Medicaid and Medicare and the Institute for Healthcare Improvement, Don was upbeat that with the right changes...

The Nuffield Trust’s fourth Health Policy Summit opens on Wednesday, bringing together senior health leaders, clinicians, policy-makers and academics. The timing is not auspicious.

The intense political wrangling over the Health and Social Care Bill has spilled out beyond Westminster and is dividing professionals in the NHS. Even at this late stage the Bill’s passage through Parliament is uncertain.

Whatever you might think of the Government’s proposals, the financial challenge that predated them is now a reality for the NHS. It is also rapidly becoming...

As the purchaser of health services for the British population, the NHS has always had to make hard choices about who is eligible for treatment, what services to cover and what criteria patients need to meet before treatment is administered.

In recent months in particular, there have been extensive debates about who bears responsibility for making these decisions and the basis on which they should be made.

These include questions about how the duties of the Secretary of State for Health should be framed, the extent to which the NHS Commissioning Board should...

The NHS Trust sector is now forecasting a surplus of just 0.1 per cent of income in 2011-12, with seven NHS Trusts alone forecasting an operating deficit of over £180 million combined. This is a marked deterioration from previous years and casts further doubt over the sustainability of many NHS Trusts.

For a great many Trusts seeking solutions to entrenched financial problems, the preference has been to merge into ever bigger units. The notable exception being Hinchingbooke Hospital, where the private health care provider Circle takes...

A centre-right coalition Government; an unsustainable hospital sector needing reform; an ageing population living with more chronic disease; calls for more integrated care; and a belief in the power of local clinical leadership to bring about such change. Sounds familiar? Well, up to a point.

Here in New Zealand, where Carol Black and I have been taking part in the Royal New Zealand College of General Practitioners' Quality Symposium, you have to pinch yourself, such is the commonality of much of the debate about our...

Last year the Archbishop of Canterbury attacked what he described as "the quiet resurgence of the seductive language of the deserving and undeserving poor".

The pressure to make huge savings within the NHS, coupled with the commissioning agenda and the introduction of private competition to that process could see the deserving and undeserving poor joined by the deserving and undeserving sick. This can't be right. After all, no one chooses to be sick.

When I hear insulting terms like "frequent flyers" being used to describe people who are sick and need...

Andrew Lansley's woes are multiplying by the hour this week as efforts mount to block the Health and Social Care Bill.

Resistance might be expected from the British Medical Association (BMA) and the Royal College of Nursing (RCN) and other unions, but it is now more widespread and even reported from deep in his own party, among cabinet colleagues. The public are bewildered and staff in the service doing a difficult job while debate rages and the...

A key challenge for NHS commissioning is to develop a ‘golden thread’ between commissioning decisions and changes in the behaviour of front-line professionals.

Over the years, we have found many ways to achieve this at the margins, for example through commissioning additional services, creating financial incentives or leading service redesign initiatives. But we have not yet found a way to weave that golden thread through the whole health and care system.

In her recent presentation at a...

The main question raised by our newly published research report: Can NHS hospitals do more with less? is why, when so much is known about what drives and can improve hospital efficiency, is there still so much variation across, and sometimes within, individual hospitals?

The areas highlighted for action read like the contents list of a textbook of health care management, with topics such as: ensuring that length of stay and day case rates are in line with international best practice; exploring ways of using new technology to improve hospital...

This is a question that we knew we had to answer in a clear and convincing manner when the Nuffield Trust and The King's Fund were asked by the Department of Health to contribute to the development of its strategy on integrated care. 

Our report of this work: Integrated care for patients and populations: Improving outcomes by working together, has now been published.

We are all too aware of the fact that 'integrated care' and 'integration' can sound rather dry and hollow as concepts, leaving most people puzzled that care could ever be...

OK, so everyone is fed up with the Bill, just getting on with it, and focusing on having a break. But here are a few things from us to ponder at the end of this unusual year.

Ideological tussles will not go away next year. Alan Garber, now Provost at Harvard and our Rock Carling fellow this year, focuses his gimlet eye on one battle line: what place for competition, what dose, what unit of, and how could it encourage integrated care rather than get in the way.

Alan brings together his long experience of analysis in the US, and his...

I have to confess that it was with some trepidation that I stepped into the Nuffield Trust one November morning to hear first-hand of the progress on Person-based Resource Allocations (PBRA), designed to allocate about one third of the total budget that will be available to clinical commissioning groups (CCGs).

The thought of trying to keep pace with Martin Bardsley’s technical wizardry around such a key issue was always likely to move me out of my comfort zone in the familiar thought patterns embedded in my basal ganglia and deliver a...

Many commentators within and without the NHS identify an under achievement of NHS commissioning. Commissioning, much like the practice of medicine, will be at its best when it conjoins art and science.

Good management has always combined both those key attributes so why generally has it been so lacking in the practice of commissioning? What has created an NHS focus on commissioning which is predominantly about setting contracts?  A focus on input procurement, and even within that narrow contractual approach there is a paucity of effective clinically-oriented contract review....

The joys of policy analysis mean the NHS Operating Framework is obligatory reading. 'Grip' is its message, no surprises there. But tucked in amongst the pages four things caught my eye.

Para 3.29 requires commissioners to link patient NHS numbers to contractual payments by March 2013. By then, it should be possible to identify routinely how much NHS expenditure goes on each individual – a crucial milestone to identify efficiencies. My bet is on information to give the NHS the biggest lift over the coming decade.

The second was para 4.24 – in response to...

Keen readers of this blog will already know about the importance of risk prediction in health. As my colleague, Dr Geraint Lewis, has pointed out: “neither doctors, nurses nor case managers [are] able to predict which patients [are] at highest risk of readmission to hospital.”

So, if the NHS is to target effectively the ever increasing rate of emergency admissions, it is clear that it needs some help from predictive risk tools.

When the...

The Government’s reform of public health services (detailed in the White Paper: Healthy lives, healthy people: our strategy for public health in England) has reignited debate about the importance and future of public health in the English NHS.  Although admittedly that discussion has sometimes been drowned out by the sound and fury provoked by the wider structural reform programme.

The key argument for retaining public health involvement in the new system...